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Medicaid Audits March 2007 COMMUNITY SUPPORT

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Medicaid Audits March 2007 COMMUNITY SUPPORT

  1. 1. Medicaid Audits March 2007 COMMUNITY SUPPORT
  2. 2. <ul><li>Arrive no later than 8:30 AM. </li></ul><ul><li>No pencils – black or blue ink only. </li></ul><ul><li>LME staff will be paired with State staff at the audit site. </li></ul><ul><li>Please – do not make zero’s with slash marks through them. </li></ul><ul><li>Ask questions. </li></ul>
  3. 3. 2007 COMMUNITY SUPPORT Audit Tool Check that the LRP has signed the plan. NEW Identifier: 4. Is the documentation signed by the person who delivered the service? [full signature with credentials/position, no initials] 8 = Repaid before audit list sent; 9 = NA 0=Not Met/No 1=Met/Yes 6=No service note 7=Provider name not available 3. Does the service plan identify the type of service billed? 3a. If NOT MET, list dates: FROM ___________ TO ___________ 2. Is the service plan current with the date of service? 2a. If NOT MET, list dates: FROM ___________ TO ___________ <ul><li>Is there a valid service order for the service billed? </li></ul><ul><li>1a. If NOT MET, list dates: FROM___________ TO___________ </li></ul>SERVICE ORDER / SERVICE PLAN / SERVICE DOCUMENTATION: RATING RATING CODES: Service Units Billed: Record #: Service Date: DOB / Age: NEW PROCEDURE CODE : MEDICAID #: SERVICE TYPE: CONTROL #: 21 – 55!! NAME: PROVIDER #: Audit Date: PROVIDER NAME:
  4. 4. <ul><li>Services must be ORDERED prior to or on the first day service is provided. </li></ul><ul><li>As of first use of the PCP on or after 6/1/06, Medicaid services are ordered by signature on the plan, by either a: </li></ul><ul><ul><ul><li>Licensed physician </li></ul></ul></ul><ul><ul><ul><li>Licensed psychologist </li></ul></ul></ul><ul><ul><ul><li>Licensed family nurse practitioner </li></ul></ul></ul><ul><ul><ul><li>Licensed physician’s assistant </li></ul></ul></ul>
  5. 5. <ul><li>Old service orders expire with first use of PCP – or when it should have been first used. </li></ul><ul><li>Only need new SO signature at the annual review or if adding a service before the annual review. </li></ul><ul><li>Old CBS order OK until first use of PCP. </li></ul>Service Orders
  6. 6. VALID SERVICE ORDER/CURRENT PLAN ~Signatures~ PAGE 11 OF PCP REQUIRED for Medicaid funded services . RECOMMENDED for State funded services. My signature below confirms that medical necessity for services requested is present, and constitutes the Service Order(s): Signature: _______________________________________________________________ Date: ____/____/_____ (Name/Title Required. Must be licensed physician, licensed psychologist, licensed physician’s assistant or licensed family nurse practitioner.) Annual review of medical necessity and re-ordering of services is due on or before:       <ul><li>Person Receiving Services: </li></ul><ul><li>I confirm and agree with my involvement in the development of this person-centered plan. My signature means that I agree with the services/supports to be provided. </li></ul><ul><li>I understand that I have the choice of service providers and may change service providers at any time, by contacting the person responsible for my plan. </li></ul><ul><li>Signature:____________________________________________________________ Date: ____/____/_____ </li></ul><ul><li>(Required when person is his/her own legally responsible person) </li></ul>
  7. 7. 2007 COMMUNITY SUPPORT Audit Tool Check that the LRP has signed the plan. NEW Identifier: 4. Is the documentation signed by the person who delivered the service? [full signature with credentials/position, no initials] 8 = Repaid before audit list sent; 9 = NA 0=Not Met/No 1=Met/Yes 6=No service note 7=Provider name not available 3. Does the service plan identify the type of service billed? 3a. If NOT MET, list dates: FROM ___________ TO ___________ 2. Is the service plan current with the date of service? 2a. If NOT MET, list dates: FROM ___________ TO ___________ <ul><li>Is there a valid service order for the service billed? </li></ul><ul><li>1a. If NOT MET, list dates: FROM___________ TO___________ </li></ul>SERVICE ORDER / SERVICE PLAN / SERVICE DOCUMENTATION: RATING RATING CODES: Service Units Billed: Record #: Service Date: DOB / Age: PROCEDURE CODE : MEDICAID #: SERVICE TYPE: CONTROL #: NAME: PROVIDER #: Audit Date: PROVIDER NAME:
  8. 8. <ul><li>Service Plans are updated/revised based on the person’s needs, target dates, provider changes. </li></ul><ul><li>PCP format must be used for all folks new to the system and for existing service recipients at the next required review on or after 6/1/06. </li></ul>
  9. 9. <ul><li>A PCP Revision page is not adequate for first use of PCP. The entire plan needs to be rewritten using the PCP format. </li></ul><ul><li>Anytime a PCP is reviewed and documented on the PCP, whether or not there are any changes , required signatures must be obtained. </li></ul><ul><li>ValueOptions does not approve PCPs. </li></ul>
  10. 10. <ul><li>Cont’d: </li></ul><ul><li>For Medicaid audit purposes, a valid plan has the REQUIRED SIGNATURES on or before services begin; and </li></ul><ul><li>COVERS THE DATE OF SERVICE being reviewed. </li></ul><ul><li>Must IDENTIFY THE SERVICE billed. </li></ul><ul><li>Must have MEASUREABLE GOALS and appropriate INTERVENTIONS . </li></ul>Service Plans
  11. 11. <ul><li>30 day window only for people brand new to the MH/DD/SAS system – not just new to the provider </li></ul><ul><li>The 30 day window is closed as soon as the PCP is developed and signed </li></ul><ul><li>To find FROM/TO dates if called ‘out’ – look for Admission/Intake form and make a copy. Explain in Comment section. </li></ul>
  12. 12. VALID SERVICE ORDER/CURRENT PLAN ~Signatures~ PAGE 11 OF PCP REQUIRED for Medicaid funded services . RECOMMENDED for State funded services. My signature below confirms that medical necessity for services requested is present, and constitutes the Service Order(s): Signature: _______________________________________________________________ Date: ____/____/_____ (Name/Title Required. Must be licensed physician, licensed psychologist, licensed physician’s assistant or licensed family nurse practitioner.) Annual review of medical necessity and re-ordering of services is due on or before:       <ul><li>Person Receiving Services: </li></ul><ul><li>I confirm and agree with my involvement in the development of this person-centered plan. My signature means that I agree with the services/supports to be provided. </li></ul><ul><li>I understand that I have the choice of service providers and may change service providers at any time, by contacting the person responsible for my plan. </li></ul><ul><li>Signature:____________________________________________________________ Date: ____/____/_____ </li></ul><ul><li>(Required when person is his/her own legally responsible person) </li></ul>
  13. 13. CURRENT SERVICE PLAN ~ Signatures ~ PAGE 11 OF PCP <ul><li>The following signatures confirm the involvement of individuals in the development of this person-centered plan. All signatures indicate agreement with the services/supports to be provided . </li></ul><ul><li>For state-funded services, if the first signature box on this page is not completed, the signature of the Person Responsible for the Plan in this box constitutes the Service Order. Complete the Annual Review date if this is the Service Order. </li></ul><ul><li>Legally Responsible Person Signature :________________ Date: ____/____/_____ </li></ul><ul><li>(Required, if other than the individual) </li></ul><ul><li>Person Responsible for the Plan Signature : ___________ Date: ____/____/_____ </li></ul><ul><li>(Required) </li></ul><ul><li>Annual Review of medical necessity and re-ordering of State-funded services is due on or before:       </li></ul><ul><li>Other Team Member Signature: ______________________ Date: ____/____/_____ </li></ul><ul><li>Other Team Member Signature: ______________________ Date: ____/____/_____ </li></ul>
  14. 14. 2007 COMMUNITY SUPPORT Audit Tool Check that the LRP has signed the plan. NEW 4. Is the documentation signed by the person who delivered the service? [full signature with credentials/position, no initials] 8 = Repaid before audit list sent; 9 = NA 0=Not Met/No 1=Met/Yes 6=No service note 7=Provider name not available 3. Does the service plan identify the type of service billed? 3a. If NOT MET, list dates: FROM ___________ TO ___________ 2. Is the service plan current with the date of service? 2a. If NOT MET, list dates: FROM ___________ TO ___________ <ul><li>Is there a valid service order for the service billed? </li></ul><ul><li>1a. If NOT MET, list dates: FROM___________ TO___________ </li></ul>SERVICE ORDER / SERVICE PLAN / SERVICE DOCUMENTATION: RATING RATING CODES: Service Units Billed: Record #: Service Date: DOB / Age: NEW PROCEDURE CODE : MEDICAID #: SERVICE TYPE: CONTROL #: NAME: PROVIDER #: Audit Date: PROVIDER NAME:
  15. 15. PLAN IDENTIFIES THE SERVICE ~ SUMMARY OF ASSESSMENTS / OBSERVATIONS~ PAGE 6 OF PCP 3 2 1 State/Medicaid/HC Target Date Duration Frequency Recommendations for Services/Support/Treatment…
  16. 16. PLAN IDENTIFIES THE SERVICE ~Action Plan~ PAGE 7 OF PCP Long Range Outcome: (Ensure that this is an outcome desired by the individual, and not a goal belonging to others.) Where am I now in relation to this outcome? SYMPTOM/OBSERVATION #:                   Status Codes: R=Revised O=Ongoing A=Achieved D=Discontinued                /  /      /  /                  /  /      /  /                  /  /      /  /   Justification for Continuation/Discontinuation of Goal Status Code Reviewed Date Target Date (Not to exceed 12 months.)                         Support / Service & frequency Who will Provide Support/Intervention / Service? Support/Intervention to Reach Goal (Taken from Supports Sections ) Short Range Goal (Taken from Preferences & Supports Sections (“What’s important TO & FOR me”)
  17. 17. 2007 COMMUNITY SUPPORT Audit Tool Check that the LRP has signed the plan. NEW Identifier: 4. Is the documentation signed by the person who delivered the service? [full signature with credentials/position, no initials] 8 = Repaid before audit list sent; 9 = NA 0=Not Met/No 1=Met/Yes 6=No service note 7=Provider name not available 3. Does the service plan identify the type of service billed? 3a. If NOT MET, list dates: FROM ___________ TO ___________ 2. Is the service plan current with the date of service? 2a. If NOT MET, list dates: FROM ___________ TO ___________ <ul><li>Is there a valid service order for the service billed? </li></ul><ul><li>1a. If NOT MET, list dates: FROM___________ TO___________ </li></ul>SERVICE ORDER / SERVICE PLAN / SERVICE DOCUMENTATION: RATING RATING CODES: Service Units Billed: Record #: Service Date: DOB / Age: NEW PROCEDURE CODE : MEDICAID #: SERVICE TYPE: CONTROL #: NAME: PROVIDER #: Audit Date: PROVIDER NAME:
  18. 18. Signatures on Documentation <ul><li>Each service note must be signed by the person who provided the service . </li></ul><ul><li>The signature shall include: </li></ul><ul><ul><li>For Professionals – credentials/degree/license </li></ul></ul><ul><ul><li>For Paraprofessionals – position name </li></ul></ul><ul><li>Do not call “out” if credentials missing </li></ul><ul><li>No initials or stamps are acceptable </li></ul><ul><li>If there is NO NOTE, Qs 4-10 are rated “6”. </li></ul>
  19. 19. COMMUNITY SUPPORT AUDIT TOOL, cont’d Be sure to reference auditor instructions! NEW! <ul><li>Do the units billed match the duration of service? </li></ul><ul><li>Does the documentation reflect treatment for the duration of service? </li></ul><ul><li>Are the service notes and service plan individualized per person? </li></ul><ul><li>a. CS Adult : Does the service note reflect one-on-one interventions with the community to develop…coping skills… </li></ul><ul><li>b. CS Child : Does the service note reflect one-on-one interventions with the community to develop…relational skills… </li></ul>6. Does the service note relate to the individual’s goals as listed in the service plan? <ul><li>Does the service note reflect purpose of contact, staff intervention and assessment of progress toward goals ? </li></ul>
  20. 20. It's as Simple as PIE! MAKE SURE DOCUMENTATION INCLUDES: <ul><li>P URPOSE of the treatment/service. This means be sure to reflect the outcome that was addressed. </li></ul><ul><li>I NTERVENTION provided. This means be sure to indicate what YOU/SUPPORT STAFF did. </li></ul><ul><li>E FFECT for the person/Progress toward goal. This means be sure to indicate what the person did or didn’t do ~ what the result was for him/her. </li></ul>
  21. 21. <ul><li>All 3 elements must be present. </li></ul><ul><li>We are not evaluating quality for this question. </li></ul><ul><li>If the intervention does not relate to the goal documented, it is “out”. </li></ul>
  22. 22. COMMUNITY SUPPORT AUDIT TOOL, cont’d Be sure to reference auditor instructions! NEW! <ul><li>Do the units billed match the duration of service? </li></ul><ul><li>Does the documentation reflect treatment for the duration of service? </li></ul><ul><li>Are the service notes and service plan individualized per person? </li></ul><ul><li>a. CS Adult : Does the service note reflect one-on-one interventions with the community to develop…coping skills… </li></ul><ul><li>b. CS Child : Does the service note reflect one-on-one interventions with the community to develop…relational skills… </li></ul>6. Does the service note relate to the individual’s goals as listed in the service plan? <ul><li>Does the service note reflect purpose of contact, staff intervention and assessment of progress toward goals ? </li></ul>
  23. 23. <ul><li>EVERY SERVICE BILLED must have a service note. </li></ul><ul><li>Each service note must RELATE TO A GOAL in the plan. Compare the purpose of the service note to the Action Plan. Watch for target dates/termination of goals/expiration of goals. </li></ul><ul><li>If goal doesn’t match exactly, determine if it relates by its intent to one of the goals. </li></ul><ul><li>Service notes can not be completed on a grid or check sheet, including for QP activities. Must be full narrative notes. </li></ul><ul><li>Cannot bill for transportation. </li></ul>Service Notes
  24. 24. <ul><li>Units billed must MATCH DURATION of service. </li></ul><ul><li>Compare the units billed (on top of audit tool) with documentation of duration in the service note. </li></ul><ul><ul><li>If more units were billed than were documented, call Q9 “out”. </li></ul></ul><ul><ul><li>If fewer units were billed than were documented, do not call Q9 “out”. </li></ul></ul><ul><li>Units billed must REFLECT TREATMENT for that duration of time. </li></ul>
  25. 25. COMMUNITY SUPPORT AUDIT TOOL, cont’d Be sure to reference auditor instructions! NEW b. a. <ul><li>a. Was an authorization in place covering this date of service? b. If “a” is NOT MET, was a request for authorization submitted prior to this date of service? c. If &quot;b&quot; is NOT MET, list dates: FROM___________TO_____________ </li></ul><ul><li>Do the units billed match the duration of service? </li></ul><ul><li>Does the documentation reflect treatment for the duration of service? </li></ul><ul><li>Are the service notes and service plan individualized per person? </li></ul><ul><li>a. CS Adult : Does the service note reflect one-on-one interventions with the community to develop…coping skills… </li></ul><ul><li>b. CS Child : Does the service note reflect one-on-one interventions with the community to develop…relational skills… </li></ul>6. Does the service note relate to the individual’s goals as listed in the service plan? <ul><li>Does the service note reflect purpose of contact, staff intervention and assessment of progress toward goals ? </li></ul>
  26. 26. <ul><li>Rate this question “9” for QP (CM-type) activity. Note must reflect direct service. </li></ul><ul><li>Measurable interventions related to skill building . </li></ul><ul><li>What skills were worked on while proceeding through activities? </li></ul><ul><li>What was taught to assist person to become more independent ? </li></ul>
  27. 27. <ul><li>Rate this question “9” for QP (CM-type) activity. Note must reflect direct service. </li></ul><ul><li>Measurable interventions related to skill building . </li></ul><ul><li>What skills were worked on while proceeding through activities? </li></ul><ul><li>What was taught to assist person to become more independent ? </li></ul>
  28. 28. COMMUNITY SUPPORT AUDIT TOOL, cont’d Be sure to reference auditor instructions! NEW b. a. <ul><li>a. Was an authorization in place covering this date of service? b. If “a” is NOT MET, was a request for authorization submitted prior to this date of service? c. If &quot;b&quot; is NOT MET, list dates: FROM___________TO_____________ </li></ul><ul><li>Do the units billed match the duration of service? </li></ul><ul><li>Does the documentation reflect treatment for the duration of service? </li></ul><ul><li>Are the service notes and service plan individualized per person? </li></ul><ul><li>a. CS Adult : Does the service note reflect one-on-one interventions with the community to develop…coping skills… </li></ul><ul><li>b. CS Child : Does the service note reflect one-on-one interventions with the community to develop…relational skills… </li></ul>6. Does the service note relate to the individual’s goals as listed in the service plan? <ul><li>Does the service note reflect purpose of contact, staff intervention and assessment of progress toward goals ? </li></ul>
  29. 29. <ul><li>Do not call Q8 out if the Service Plan is not valid – evaluate for individualized notes. </li></ul><ul><li>Service Plans should not be so GENERIC that they could be used for anyone. </li></ul><ul><li>Service Plans per provider should VARY FROM PERSON TO PERSON. </li></ul><ul><li>Service Notes must be INDIVIDUALIZED PER PERSON & PER SERVICE EVENT </li></ul><ul><li>In clear cases of “cookie cutter” plans or notes , Q8 will be called “out” </li></ul>Individualized Notes/Plans
  30. 30. COMMUNITY SUPPORT AUDIT TOOL, cont’d Be sure to reference auditor instructions! NEW b. a. <ul><li>a. Was an authorization in place covering this date of service? b. If “a” is NOT MET, was a request for authorization submitted prior to this date of service? c. If &quot;b&quot; is NOT MET, list dates: FROM___________TO_____________ </li></ul><ul><li>Do the units billed match the duration of service? </li></ul><ul><li>Does the documentation reflect treatment for the duration of service? </li></ul><ul><li>Are the service notes and service plan individualized per person? </li></ul><ul><li>a. CS Adult : Does the service note reflect one-on-one interventions with the community to develop…coping skills… </li></ul><ul><li>b. CS Child : Does the service note reflect one-on-one interventions with the community to develop…relational skills… </li></ul>6. Does the service note relate to the individual’s goals as listed in the service plan? <ul><li>Does the service note reflect purpose of contact, staff intervention and assessment of progress toward goals ? </li></ul>
  31. 31. <ul><li>Services must be AUTHORIZED either by the LME or ValueOptions. </li></ul><ul><ul><ul><li>LME authorization for children is good through 7/14/06. </li></ul></ul></ul><ul><ul><ul><li>LME authorization for adults is good through 8/14/06. </li></ul></ul></ul><ul><ul><ul><li>After these dates, only VO may authorize. </li></ul></ul></ul><ul><li>Service dates reviewed during audit must be covered by a valid authorization if not within first 30 day window . </li></ul>
  32. 32. <ul><li>If the provider does not have their authorization, check the VO spreadsheet . </li></ul><ul><li>If no authorization, ask for evidence of having submitted a request . </li></ul><ul><ul><li>Fax Receipt </li></ul></ul><ul><ul><li>QP note stating when request submitted </li></ul></ul><ul><ul><li>Initial/date by staff on fax sheet </li></ul></ul><ul><li>If 11a = 1, 11b MUST be rated 1. No 9’s in Q11, unless in first 30 days. </li></ul>
  33. 33. OF CORRECTION REQUIRING PLANS
  34. 34. PLANS OF CORRECTION <ul><li>May be required for Questions 1-11. </li></ul><ul><li>Are used to address issues found out of compliance that represent systemic issues. </li></ul><ul><li>Contain standardized language relating specifically to the question asked. </li></ul><ul><li>Recommendations not requiring corrective action, may be made for lower level issues or best practice intent. </li></ul>
  35. 35. PLANS OF CORRECTION <ul><li>Original “Pink Sheet” from first audit will be in packets. Do not start new ones. </li></ul><ul><ul><li>Add new date to top of Pink Sheet </li></ul></ul><ul><ul><li>Initial and date any additions to the Pink Sheet </li></ul></ul><ul><ul><li>No deletions of earlier entries </li></ul></ul>
  36. 36. COMMUNITY SUPPORT SERVICES Medicaid Audit 2006 / 2007 REPORT SUMMARY INFORMATION LME: __________________ Last Date of this Audit: _____________ COMMUNITY SUPPORT Provider : ____________________________________ Team Leader: ________________ Auditor Completing Form ____________ <ul><li>Team Leader Check List: </li></ul><ul><li>All blanks filled in: Record #s, Ratings, Signatures, etc. </li></ul><ul><li>All items out of compliance have a comment (that makes sense) on the bottom. </li></ul><ul><li>All items out of compliance have appropriate copies attached. </li></ul><ul><li>No Plan of Correction required </li></ul><ul><li>No Recommendations made </li></ul><ul><li>Plan of Correction is required as follows (for Medicaid audits): </li></ul>Complete this form for each CS provider
  37. 37. COMMUNITY SUPPORT SERVICES Medicaid Audit 2006 / 2007 REPORT SUMMARY INFORMATION, cont’d <ul><li>A. Ensure there is a valid service order for the service billed. </li></ul><ul><li>B. Other: Ensure that </li></ul>2. A . Ensure the service plan is current with the date of service. B. Other: Ensure that
  38. 38. COMMUNITY SUPPORT SERVICES Medicaid Audit 2006 / 2007 REPORT SUMMARY INFORMATION, cont’d 3. A. Ensure the service plan identifies the type of service billed. B. Other: Ensure that 4. A. Ensure that all documentation is signed by the person who provided the service. B. Ensure that there is a service note entry for every service event billed. C. Ensure that signatures on documentation include the degree, credentials, license (for professional staff), or the position name for paraprofessional staff. D. Other: Ensure that
  39. 39. COMMUNITY SUPPORT SERVICES Medicaid Audit 2006 / 2007 REPORT SUMMARY INFORMATION, cont’d 5. A. Ensure that all service notes reflect the purpose of contact. B. Ensure that all service notes reflect staff intervention. C. Ensure that all service notes reflect the assessment of progress toward goals. D. Other: Ensure that 6. A. Ensure that all service notes relate to goals listed in the service plan. B. Other: Ensure that
  40. 40. COMMUNITY SUPPORT SERVICES Medicaid Audit 2006 / 2007 REPORT SUMMARY INFORMATION, cont’d 7. A. Ensure that the Community Support Adult service notes reflect 1:1 interventions with the community to develop interpersonal & community coping skills including adaptation to home, school & work environments B. Ensure that the Community Support Child service notes reflect 1:1 interventions with the community to develop interpersonal & community relational skills including adaptation to home, school and other natural environments. C. Other: Ensure that
  41. 41. 8. A. Ensure that all service note/service plans are individualized per person. B. Other: Ensure that 9. A. Ensure that service notes indicate the duration of the service and that it matches the units billed. B. Other: Ensure that COMMUNITY SUPPORT SERVICES Medicaid Audit 2006 / 2007 REPORT SUMMARY INFORMATION, cont’d
  42. 42. Community Support Medicaid Audit 2006 / 2007 REPORT SUMMARY INFORMATION, cont’d 10. A. Ensure that service notes reflect treatment for the duration of service that was billed. B. Other: Ensure that <ul><li>A. Ensure that a service authorization is in place </li></ul><ul><li>covering all dates of service. </li></ul><ul><li>B. Other: Ensure that </li></ul>
  43. 43. Community Support Medicaid Audit 2006 / 2007 REPORT SUMMARY INFORMATION, cont’d <ul><li>Recommendations, not requiring Corrective Action: </li></ul><ul><li>1. </li></ul><ul><li>2. </li></ul>Summary comments for this survey: General Comment for the survey: Yes No This provider received their initial letter announcing their Medicaid audit on ______________.  The letter outlined the complete audit process and indicated all materials that were needed on-site for the audit.  This letter also included copies of the audit tools, audit instructions and plan of correction information.  On ______________, this provider received the list of records to be audited on their scheduled audit date of ___________.  At the beginning of the audit, the items needed for the audit were reviewed and the provider was informed of the deadline time that day to have all items available. This provider was unable to provide the following information.___________________________ _____________________(The provider is waiting for this agency:____________________________________________________ to provide this documentation:__________________________________________________________

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